Population Health Assessment: Baltimore City - Essay Example

Population Health Assessment: Baltimore City Introduction: Baltimore City is located in the central Maryland along the tidal portion of the Patapsco River. It is the only city in the state of Maryland not located within a county. In the 1904 fire which destroyed about 2,000 buildings left Baltimore city with great amount of debts and the city decay was so much that about 45,000 homes were considered uninhabitable in 1947 (City-Data.com, n.d.) . Section 1: Assessment of Risk The epidemiological data: Although the city of Baltimore is the largest U.S. seaport in the Mid-Atlantic, it is still one of the poorest cities in Maryland. The population of Baltimore City is made up of nearly two-thirds Black and one third White, with an insignificant number of other races (Baltimore City Health, 2008). The mortality rate of Baltimore is 15%. The leading Cause of Death (Mortality) in Baltimore City is Heart Disease for all ages, however, for ages 35-44, HIV/AIDS is the leading cause of death, while homicide is the leading cause of death for ages 25-34. Leading cause of morbidity is poor nutrition, which was rated at 72.8%, followed by high blood pressure at 29.95, lack of exercise at 28.6% and obesity at 28%, (Baltimore City Health, 2008). Key risks for this area: Power plants and other industrial companies are among the key risks in this city. According to the environmental Scorecard website, in 2002, Baltimore (city) county ranked among the dirtiest/worst 10% of all counties and cities in the US. Twelve percent of the houses in this city have lead and this is because 140,000 of the houses in this county were built before 1950 (scorecard.good guide.com). Baltimore (city) county, ranked number one among the counties in Maryland with the highest ambient air concentrations of lead and number 4 among the counties in Maryland with the greatest reported releases of lead to air. Mobile sources including both on-road vehicles (such as cars, trucks and buses) and off-road equipment (such as ships, airplanes, agricultural and construction equipment) are high sources of pollution, contributing to health risks from hazardous air pollutants in Baltimore City; these sources contribute up to 93% of this county’s added cancer risk (scorecard.good guide.com). The most common contaminants in Baltimore (City) County detected at Superfund sites are ethylbenzene, while the one released to land at TRI facilities is a manganese compound.  Baltimore city ranks number 3 in health risks from criteria air pollutants among all the counties in Maryland. This county has 4,663,104 person-days in exceeding the National Ambient Air Quality Standards (NAAQS). Also, Baltimore (City) County percentage of surface waters with reported problems (state + EPA data) is 31%, while, the number of water bodies with reported problems (as reported by the state) is 49. The leading sources of water quality problems are rivers, streams and creeks (U.S. EPA, epa.gov).  The salutogenic factors (Positive factor): Salutogenic factors focus on supporting and increasing well-being. Engstrom & Janson (2009) stated that the salutogenic theory, which was introduced by Antonovsky, focuses on the causes of health instead of the causes of illness, in what he called the “health-ease versus dis-ease continuum” (1979). This allows for further research as to why certain people remain healthy, while others are often sick. This closer observation of the combinations of health, stress and coping abilities of the individual provide answers to the supporting of health. There are about 30 accredited hospitals in Baltimore, ranging from world-renowned hospital Johns Hopkins, to Maryland General Hospital. Johns Hopkins is a private research university in Baltimore, with campuses in other cities in Maryland, Washington D.C., China, Singapore and Italy. In the search for better health, Johns Hopkins University has implemented a variety of initiatives to assist in sustainability of the environment. In 2007, they introduced the use of electric vehicles for on campus transportation, introduced a greater source of organic and locally grown produce and seafood and organically grown coffees. They also started implementing certifications for energy retrofitting in several of their buildings, resulting in a 50% decrease in energy consumption (greenreportcard.org). Both of these hospitals have multiple specialized services, such as cardiac rehabilitation, psychiatric and drug and alcohol rehabilitation programs. The presence of these healthcare institutions and healthcare providers within the City of Baltimore promotes active participation of health promotion information dissemination. In order to motivate and maintain health, this community must be made aware of the available resources. According to the Baltimore City Community Health Survey of 2009, although there are many resources available, not many people are taking advantage of them. In this survey, the Social Determinants of Health (SDoH) are a blanket term for the promotion of these resources. They include opportunities for employment, higher education, healthy food and housing, healthcare, sate neighborhoods, parks and transportation. The SDoH are responsible for the inequities of health, and are putting forth more effort to recognize the social and economic positions (SEP) are huge determinants of whether people have control over their health and resources. In Baltimore, 13% of the survey study reported as having been incarcerated, Whites were 3 times more likely than Blacks to be in a high-income level grouping were and that Blacks were 3 times more likely than Whites are unemployed. People that had a BA degree or less were 3 times more likely to claim poor health, the lowest income group was 4 times more likely than those in the highest income group to report poor health as well. The feeling of danger in their neighborhoods was starkly different. The lowest income groups were 14 times more likely than the higher income group to view their neighborhood as dangerous. In keeping with the low-income group versus the high-income group, the lower were 3.5 times more likely to report roaches in their homes, were 6 times more likely to have concerns about having enough to eat and 3 times as likely to have trouble paying their heating bill (Baltimore City Health Department, 2010). Baltimore residents are known to spend more time outdoors, at the street corners, talking with each other, everybody seeming to know everybody. This makes it easy to disseminate of health information, but it does not seem to be working. Approximately 15% of the Baltimore adult population reported having a poor state of mental health, which is higher than Maryland as a whole for the last 5 years (Sharfstein, 2008). Poor mental health often leads to substance abuse, which is a brutal killer and major problem for Baltimore. Heroin is the most commonly associated drug with death as 78% of all drug deaths were from heroin from 1997 - 2007 (Sharfstein, 2008). Alcohol abuse was also considered, as was cocaine, but heroin was the worst. Alcohol and heroin were both the primary addictions for which individuals sought treatment, but other opiate use has soared, more than doubling admission rates versus other drugs. This is a massive concern to everyone in Baltimore, and around the country. The pathogenic factor Since socioeconomic factors play a part in community health, encouragement through stay-in-school programs and job training will be helpful in keeping Baltimore City healthy. Pathogenic factors, which could help disease prevention for Baltimore City include; increase in physical activity; a healthier diet, such as vegetables and fruits; regular checkups; decrease in alcohol intake, participation in smoking and substance abuse cessation programs and; regular prenatal. The gaps in capacity, quality, and community demand for high-impact services are very critical. According to Baltimore City Health (2008), some of these gaps are the lack of health insurance, with an estimated 13.2% of Baltimore City residents being uninsured. This lack of health insurance is leading to citizens leaving their needed healthcare unmet, as they simply cannot afford to see a doctor. With 22.9% of the population being below poverty level, 58.5% of the population having a very low income status and 41.3% of the very low income status population in need of critical housing (fed stats.gov), Other gap areas mentioned by Baltimore City Health (2009) include an inadequate number of primary care and reproductive health appointments. This leads to low birth weights, pre-term births and unexpected infant deaths (Baltimore City Health Dept., 2009). Insufficient programs for exercise in many areas, primarily in the school systems: With cuts to school wellness policies, lack of physical education and no recesses, Maryland children are at very high risk of obesity and its related effects in later life (Flamholz, 2011). Poor access to nutritious food: According to the Physicians Committee for Responsible Medicine, (PCRM), “Baltimore City school lunches have earned a sub par grade of ’D’, and improvement of previous ’F’s”. (Kaplan 2008). This lack of nutritious food is a leading cause in childhood obesity, which will strain an already laboring health system. Roan, Teague & Nicole (2008) stated that a RAND Corporation found very high rates of preventable hospitalization in Baltimore. The report showed that the city is undergoing a shortage in ambulatory care, with 150,000 visits per year or more occurring throughout Baltimore City. The rates of ambulatory care sensitive inpatient hospitalization and emergency department rates were highest in the Eastern part of Baltimore for youth. Among adults, the same rates were the highest in the Southwest part of Baltimore. Most commonly, people use ambulances for asthma, hypertension and diabetes related problems (Gresenz, et al., 2009). This shortage brings about excessive wait before receiving care, thereby causing reluctance to seek emergency care. This also leads to a sicker and unhealthy community, as many of the primary reasons for seeking ambulatory care either are or can be critical. . Community rating on various determinant of health: Baltimore city ranked last (24 out of the 24 counties in Maryland) in the 2011 County Health Rankings which Measures Health Come (mortality and morbidity); Health Factors, such as health behaviors, clinical care, social-economic, and physical environment (County health, 2011). Only 76.9%, of the resident attended High school or higher compare to the US average which is 84.9%. The City Median Household Income is $38,738.00, while Families below poverty level is 16.2% (U.S. Census Bureau, 2010). The following data from Baltimore City Health, 2008 shows that: 17 % of Baltimore City Resident has no Health Insurance; the percentage of Low Birth Weight Births, Baltimore City by Race is 15%; Infant Mortality Rate, Baltimore City by Race and Maryland, is 11.5; Elevated Blood Lead Levels among Children Tested, Baltimore City is 68.5%; Assault (Homicide): Age-Adjusted Mortality Rates is 38.6 per 100,000 in 2006; Percentage of Adults Reporting Eight or More Days of Poor Mental Health Status per Month in 2007 is 15%.; In 2007, Baltimore City recorded 230 death from Intoxication Deaths Associated with Drugs of Abuse or Alcohol; Chronic Alcohol Use among Baltimore City and Maryland is 4.5%; In 2006, there were 162.0 HIV Incidence Rate Per 100,000, and 86.6 AIDS Rate Per 100,000 newly diagnosed cases; Primary & Secondary Syphilis Incidence Rates is 20.9 per 100, 000. ; Gonorrhea Incidence Rates, is 474.5 per 100, 000; Tuberculosis Incidence and Incidence Rates, Baltimore City is 47 per 100, 000. ; Percentage of Middle School Students who Smoked Cigars, Cigarillos, or Little Cigars in the Past 30 Days; Baltimore City 2006 was 6%.; Percentage of Adults who Currently Smoke Cigarettes, in 2007 was 28% ; Percentage of Children Age 2-5 years Enrolled in the WIC Program Population, Baltimore City was 13% ; Percentage of High School Students Classified as Obese (and 95% CI) According to Body Mass Index (BMI), Baltimore City was 17.9. ; Diseases of the Heart: Age-Adjusted Mortality Rates, in Baltimore City was 266.9 per 100,000. ; Cerebrovascular Disease: Age-Adjusted Mortality Rates in Baltimore City was 52.6 in 2006. ; Cancer: Age-Adjusted Mortality Rate, Baltimore City is 228.9 per 100, 000. ; Diabetes Mellitus: Age-Adjusted Mortality Rates, Baltimore City is 35.3 in 2006 (Baltimore City Health, 2008). Section 2: Analysis Baltimore City is not completely bad, it does have something going for it, as mentioned above, the city has numerous hospitals, although majority of staff come from outside the city. However, there are many factors that determine the health of a community, such as quality of health care, individual behavior, education and jobs and the environment. Any problem with any of these factors would affect the health of a community. Air pollution is a serious issue in Baltimore. Although, Air quality in the country's cities areas are improving speedily, due to mostly drops in motor vehicles' emissions of air pollutants, Baltimore’s dominant air issue is not from motor vehicles; it is as a result of all the power plants and other industrial companies and the fact that most houses in Baltimore were built before 1950. Lead-based paint remains a main exposure avenue in these older homes. The lethal effects of mercury and lead on humans are a known fact; it damages neurological development. In July 18, 1996, the state of Maryland encouraged residents of the Baltimore city to take precautions because air quality was expected to approach unhealthful levels. "Code Orange," is confirmed when the air is reaching unhealthy stages, when the ozone readings are 89-99. It is "Code Red," or dangerous, when the index approaches 100 or above (Staff Report, 1996). Over the last decade, federal and state regulators have been progressively raising the bar for the most severe pollutants: volatile organic compounds, nitrous oxide and sulfur dioxide that form ground-level ozone, the main component of smog (Air quality looking, 2010). According to Mirabella (2011), the Port of Baltimore is stepping up efforts to minimize the harmful effects of port operations on the air, water and soil. Government officers are stepping up to do something about these issues. The Port of Baltimore, which was a source of pollution from ships, trucks and heavy equipment, is starting to clean up. Another area of concern is the city’s poverty level. Although Baltimore City poverty level has decreased tremendously from 41.4% in 2000 to 16.2 in 2010, it is still high, compared to the national average, which is 9.9%. The socioeconomic factor of Baltimore is a major contributor to the city’s health risk.  The extreme violence, drug habits and high drop-out rate from high school in Baltimore city are the results of low socioeconomic position. According to the Baltimore Department of Health (2011), education and income are two common measures of socioeconomic position (SEP). They noted that health improves steadily as levels of income and education goes up. Also, Baltimore Department of Health believes that having a higher socioeconomic position gives people greater access and control over health promoting and improving resources and opportunities, thus enabling them to live longer and healthier lives. In view of Baltimore City’s statistical data, it is obvious that they are at greater health risk than statewide and in the U.S. as a whole. Evidence of health disparities between Baltimore City and other areas of Maryland is shown in the County health (2011) report as Baltimore City ranked 24, which is the lowest of all the counties. County health (2011) documented grave disparities in mortal­ity, morbidity, risk behaviors, and hazardous environmental expo­sures. It is noted that Baltimore ranked last in all these areas. Baltimore rated poorer than the rest of Maryland and the rest of the country on several health indicators, including heart disease, stroke, cancer, infant mortality, and asthma (Baltimore City Health, 2010). Mortality from HIV/AIDS has continued to increase, at rate greater than that of the whole of Maryland. Mortality from HIV/AIDS increased 22% in Baltimore and 12% in Maryland between 2000 and 2003. Among the Baltimore City residents, there are notable differences in health. According to Baltimore City Health (2010), there are also great disparities among Baltimore residents. They reported income and education levels as the largest area of disparities among Baltimore residents; the city received “F”s on 26 of 43 indicators. Racial and ethnic disparities were another area of concern. Blacks rated lower than the other races on 21 of 29 indicators. In 2006, the HIV/AIDS mortality rate of Baltimore City African Americans was almost 8 times higher than Baltimore Whites, while the Hispanics rate was only 2 times higher than white (Baltimore City Health, 2008). Baltimore City received a “D” grade in Health disparity report card of 2010 (Baltimore City Health, 2010). Baltimore City Low birth weight rate is 36% higher than that of Maryland State. Healthy People 2010’s goal is 5.0%, the National statistic is 8.2%. Baltimore City at 12.8 in 2007 is obviously high and requires urgent attention. “Low Birth Weight: Babies weighing less than 2,500 grams (approximately 5.5 pounds) at birth Importance: Birth weight is the most important factor affecting neonatal mortality and is a significant determinant of post-neonatal mortality; with a low birth weight, babies are at higher risk for developmental disabilities and respiratory problems”. (Baltimore City Health, 2008). Also, low birth rate is the leading cause high infant mortality, and according to Vital statistics website, “the rate of infant death in Baltimore was 11.3 per 1,000 live births in 2007, which is the second highest of Maryland jurisdictions, and higher than the rates of some developing countries”. Another heightened issue is homicide. Although homicide is the second leading cause of death among young adults age 15-24 years nationwide, the rate of homicide at 38.5 per 100,000 is tremendously higher than that of Maryland which is 10.2 per 100,000 and National which is 6.1 per 100,000 (Baltimore City Health, 2008). Forty percent of Baltimore’s homicide suspects and defendants are charged with felony gun crimes shootings, attempted murders, armed robberies have prior gun arrests (O’Doherty, & Goldstein, 2011). According to city-data.com research, there were 1732 registered sex offenders living in Baltimore, Maryland in April 2010, making the ratio of residents to sex offender 368:1. There are evidences that Baltimore is taking some actions to decrease crime. According to Mayor Rawlings-Blake, new state gun legislation has taken Baltimore to the next level and has help reduce gun violence further. In 2010, Baltimore City Homicide went to down 6%, and Baltimore reported the lowest homicide count since 1985, a 25-year low (Office of the Mayor, 2011) Regardless of all the issues facing Baltimore City, there is a sense of community in Baltimore; there is always some type of fair going on in the street during the summer. Judging by numerous nicknames Baltimore is known by, names such as ‘America's Comeback City’, ‘Charm City’, ‘Crab Cake Capital of the World’, ‘Monument City’, ‘The City of Firsts’, ‘The City That Reads’, and ‘The Greatest City in America’ (City-Data.com), the Baltimore residents love Baltimore, they just need some help getting their health and habits together. Section 3: The Problem Problem statement: Low birth weight led to the greatest number of deaths (26% of all deaths) among Baltimore City infants in 2006, and it is 36.8% greater than Maryland State. Section 4: Planning, Implementation and Evaluation Strategies Utilized in the Past: Many populations have implemented a variety of strategies to tackle the problem of low birth weight. According to Lightwood, Phibbs, & Glantz (1999), in the 1980s, maternal smoking contributed to between 17% and 26% of LBW in the United States. Lightwood, Phibbs, & Glantz (1999), showed that smoking cessation programs have significant impacts on preventing low birth weight. “The expected national average value of the immediate reduction in medical costs associated with treating LBW is $511 per smoking pregnant woman. In other words, a health insurer or health maintenance organization could spend up to $511 to create a new nonsmoker and break even by eliminating the expected additional costs of delivering a LBW infant to that woman. A 1% absolute reduction in smoking prevalence each year throughout 7 years would result in 57 200 fewer LBW infants with a total cumulative savings of $572 million in undiscounted medical costs in the United States” (Lightwood, Phibbs, Glantz, 1999). In Canada, while prenatal education is available to all women, populations such as immigrant Punjabi women residing in the Lower Mainland of British Columbia do not have access to these services (Bhagat, Johnson, Grewall, Pandher, Quong, &Triolet, 2002). In order to provide access to this population, a collaborative methodology was used with participants from various service agencies and the community. The team consisted of public health nurses, community program managers, community outreach workers, women from the Punjabi community and an academic head. “The mobilization strategy involved creating a platform to communicate with the community about prenatal health and health care, creating ‘buy-in’ from the physicians serving the women of the community and providing prenatal sessions that built on the existing knowledge of the women” (Bhagat, Johnson, Grewall, Pandher, Quong, &Triolet, 2002). These strategies were successful due to the commitment from the community and agency partnerships and various mobilization strategies. Canada Prenatal Nutrition Program (CPNP) is another community program developed program in Canada. It was created to reduce the incidence of low birth weights, optimize the health of both baby and mother and motivate new mothers to breast feed their newborn. The program objective is to provide food supplementation, nutritional counseling, support, education, referral and counseling on lifestyle issues to pregnant women living in low income areas, poverty, teens, or women with limited access to health care (Public Health Agency of Canada, 2001). According to Public Health Agency of Canada (2001) “the goal of the Canada Prenatal Nutrition program is to improve birth outcomes by increasing access to prenatal care”. Results showed that CPNP projects are successfully reaching pregnant women most at risk for poor birth outcomes. “There are currently 350 CPNP projects serving over 2,000 communities across Canada. In 2001, over 44,650 women participated in CPNP projects and over 36,300 referrals were made to other programs/services. Positive impact results include a breastfeeding initiation rate of 79%” (Health Agency of Canada, 2001). This program was successful because when women are given resources, the ability to create a community network and unbiased information, they are motivated to change their lifestyle and their self-esteem is enhanced. A. Design and describe at least 4 strategies to deal with the problem at the Population level The 2010 goal is to reduce low birth weights to 5%, and since Baltimore City’s rate is 12.8%, it is crucial to reduce the City low birth weight rate with well formulated strategies (Baltimore, 2008). The prevention of low birth weight will bring about reduction in infant motility. Risk factors, social issues, and preventive services must be identified to effectively address the prevention of low birth weight births (York and Brooten , 1992). Strategy 1 Mobilize the community to support the health of young women and men before pregnancy is essential for improved birth outcomes, by providing resources in Baltimore that support health before pregnancy. Before they become pregnant, it is important to have healthy men and women in order to create better birth outcomes. This allows for resources within Baltimore for just this purpose. They include: Adolescent clinics, Reproductive health clinics, Pregnancy testing, Substance abuse treatment centers, Schools with mental health services A 24/7 mental health crisis line, Federally Qualified Health Center systems, reproductive health clinics service, family planning clients annually in the pre- and post pregnancy periods and pregnancy testing services offered by both Planned Parenthood and the city (Baltimore City Health Dept., 2009) Strategy 2 Provide an in school program for early identification of pregnancies and referral to appropriate care and support are essential for avoiding having a low weight baby. Examples of such resources outreach workers, social workers, and Baltimore HealthCare Access and in home visiting programs for pregnant and post-partum women (Baltimore City Health Dept., 2009). Strategy 3 Formulate a City program that will collaborate with outside clinicians to provide free prenatal check out, text message reminder of appointment due date and gestational period updates and expectations. The care that occurs before conception is imperative in the reproductive health of the mother and her nutrition. It can also help the mother to manage or avoid chronic health conditions, which can have a huge effect of the health of both mother and child. These clinics also allows for screening and referrals to mental health, substance abuse, domestic violence and smoking cessation services (Baltimore City Health Dept., 2009). Strategy 4 Improve quality of care by creating better policies; both at the City and federal level to improve healthcare. Providers’ accountability in the following areas; health services for adolescents and young adults; services specific to pregnant women, such as home visiting and; services for mothers and infants after delivery. The Health Department, who sets up standards, educates providers and implements methods of evaluation must be involved in the formulation of these policies (Baltimore City Health Dept., 2009). Outcome Evaluation methods: By implementing these strategies, the rate of preterm births can be reduced by at least 10%, reduce the rate of low birth weights by at least 10% and reducing infant deaths from unsafe sleep by at least 30%. Over the course of time, this will lead to even fewer low birth rate babies, lower preterm births and fewer infant sleeping deaths. This can only improve our future as a city and as a nation. Evaluate the health of the unborn throughout the pregnancy to determine how the baby is doing to avoid and/or manage complications, such as infection, hemorrhage and eclampsia. Use of follow-up questionnaires to determine the wellbeing of the young women and men before conception will improve birth outcomes. Determining what habits they have that might impact the health of a baby and how they are coping with it. School based programs can be evaluated using the Youth risk Behavior Survey assess Youth awareness (Centers for Disease Control, 2011). The city performance indicators would show a decrease in low weight births and notably improve the health of the mother and father before conception. Assess for the following outcome with the City vital statistics; 1. Decrease in complications, such as infection, hemorrhage and eclampsia due to increased Prenatal and obstetric care. 2. Improved nutrition of the mother promotes healthy births and helps combat obesity. 3. Decrease in violence during pregnancy due to community resources awareness 4. Interventions through home visits have reduced low birth weights and increases intervals between pregnancies. Also, follow up on bills to assure that the proper steps are being taken to repay and that it will improve the health services to be received by the adolescents and young adults; services specific to pregnant women, such as home visiting; and services for mothers and infants after delivery (Baltimore City Health Dept., 2009) Although the above strategies are targeted at decreasing low weight birth, one cannot ignore the underlying issues in reference to poor birth outcomes. Those include poverty, inadequate or unstable housing, unemployment, racism, genetics, and environmental exposure and lower than average levels of education. These strategies will not directly assist in these areas; however, it would be in keeping with the rest of the city’s efforts on addressing these issues. References: Antonovsky, Health, Stress, and Coping: New Perspectives on Mental and Physical Health, Jossey-Bass, San Francisco, Air quality looking up: ur view: Maryland has made air quality strides, but this is no time to breathe easy. . (2010, May 05). Baltimore Sun, Retrieved from http://articles.baltimoresun.com/2010-05-10/news/bs-ed-0510-airquality-20100510_1_air-quality-fight-against-air-pollution-power-plants Baltimore City Health Department analysis of data from the Maryland Department of Health and Mental Hygiene - Maryland Vital Statistics Annual Report and the Baltimore City Vital Statistics Profile. Baltimore City Health Department. The Family League of Baltimore City (2009, April). The Strategy to Improve Birth Outcomes in Baltimore City. Retrieved from http://www.baltimorehealth.org/info/2009_04_08.BirthOutcomesPlan.pdf Baltimore City Health Department, Office of Epidemiology and Planning. (2008). Baltimore city health status report Baltimore City, Maryland: Retrieved from www.baltimorehealth.org/dataresearch.html Baltimore facts - Freebase. (n.d.). Retrieved from http://www.freebase.com/view/en/baltimore Baltimore, Maryland (MD) profile: population, maps, real ... (n.d.). Retrieved from http://www.city-data.com/city/Baltimore-Maryland.html Baltimore: History: City Guide, weather and facts galore from ... (n.d.). Retrieved from http://www.answers.com/topic/baltimore-history Bhagat, Johnson, J., Grewall, S., Pandher,P., Quong, E., Triolet, K.(2002) Mobilizing the Community to Address the Prenatal Health Needs of Immigrant Punjabi Women Public Health Nursing, 19 (3). PP 209-214 Centers for Disease Control, (2011). YRBSS: Youth Risk Behavior Surveillance System. Retrieved from: http://www.cdc.gov/HealthyYouth/yrbs/index.htm County health rankings: mobolizig health action toward community health. (2011). Informally published manuscript, A collaboration of the Robert Wood Johnson Foundation and the University of Population Health Institute, The Robert Wood Johnson Foundation and the University of Wisconsin, Wisconsin . Retrieved from http://www.countyhealthrankings.org/maryland/downloads-and-links Engstrom, L, & Janson, S. (2009). Predictors of work presence – sickness: absence in a salutogenic perspective. Informally published manuscript, Department of Public Health Sciences, Karlstad University, Karlstad, Sweden. Retrieved from DOI 10.3233/WOR-2009-0876 Environmental Protection Agency, (2011). National Ambient Air Quality Standards (NAAQS). Retrieved from: http://www.epa.gov/air/criteria.html Flamholz, Mindie (2011). When it comes to exercise, Md. Schools are slacking. Baltimore Sun. Retreived from: http://articles.baltimoresun.com/2011-03-29/news/bs-ed-exercise-letter-20110329_1_physical-education-daily-recess-alvin-thornton Kaplan, Michael 2008). Where’s the spinach? Healthy food makes healthy minds. Indypendent Reader. Retreived from: http://indyreader.org/content/wheres-spinach-healthy-food-makes-healthy-minds Mapstats, (2009). Baltimore (city), Maryland. Retrieved from: http://www.fedstats.gov/qf/states/24/2404000.html Maryland Vital Statistics, Department of Health and Mental Hygiene, 2007. Available online at http://www.vsa.state.md.us/. Mirabella, L. (2011, March 7). Port of Baltimore goes green: shippers and terminal take steps to clean up air, water and soil. Baltimore Sun. Retrieved from http://articles.baltimoresun.com/1996-07-18/news/1996200122_1_ground-level-ozone-air-quality-index Lightwood, J. M, Phibbs, C.S, & Glantz, S. A. (1999). Short-term health and economic benefits of smoking cessation: low birth weight. Pediatrics, 104(6): 1312-20 O’Doherty, R, & Goldstein, S. Office Of the Mayor of Baltimore City, Mayor's Office on Criminal Justice. (2011). Safer city / gun statistics: the facts on tougher sentencing for illegal gun possession Baltimore City, Maryland: Policy and Communications. Retrieved from http://www.baltimorecity.gov/Residents/HealthSafety/SaferCity/GunStatistics.aspx Office Of the Mayor of Baltimore City, (2011). Homicide, shootings, overall gun crime decline in 2010 Baltimore City, Maryland: Baltimore City News & Press Releases. Retrieved from http://www.baltimorecity.gov/OfficeoftheMayor/NewsPressReleases/tabid/66/ID/802/Mayor_Rawlings-Blake_Commissioner_Bealefeld_Report_2010_Crime_Reduction.aspx STAFF REPORTS. (1996, July). Poor air quality expected today state urges caution. Baltimore Sun. Retrieved from http://articles.baltimoresun.com/1996-07-18/news/1996200122_1_ground-level-ozone-air-quality-index. Roan, G. C., Teague, R., Nicole, L. (2008). Ambulatory Care Sensitive Hospitalizations and Emergency Department Visits in Baltimore City US Department of Health and Human Services: Healthy people 2010: midcourse review. Rockville, MD: US Department of Health and Human Services; 2007. Available at http://www.healthypeople.gov/data/midcourse. York, R, & Brooten, D. (1992). Prevention of low birth weight. NAACOG's Clinical Issues in Perinatal & Women's Health Nursing, 1(3), 13-24. Read More